Peds Exam 2 (unit 3.3)

What shunts close at birth

foramen ovale, ductus venosusm ductus arteriosis

murmurs

heart sounds that reflect the flow of blood within the heart

may occur during systole, diastole or both

3 classifications of heart murmurs

innocent -> noise from normal blood flow

functional -> increased cardiac output

organic -> structural change in the heart

Heart sounds

S1 -> closure of tricuspid and mitral valves

S2 -> closure of aortic and pulmonic valves

Congenital heart disease (CHD) - incidence/causes

5-8 in 1,000 births

higher than normal with

- maternal rubella (measles) or viral illness

- poor prental nutrition

- maternal alcoholism

- maternal age over 40

- maternal diabetes

Acyanotic heart defect

blood is shunted from the left side to right side of heart due to structural defect in the interventricular septum

often retain normal levels of oxyhemoglobin sats in circulation (normal spo2 levels makes hard to tell because child will present as normal)

- VSD, ASD, PSD, coarctation

What is an atrial septal defect (ASD)?

A condition where the wall between the right and left atria does not close properly, leaving a hole between the two atria.

What is the incidence rate of atrial septal defect (ASD)?

4 in 100,000.

How does atrial septal defect (ASD) typically present when no other congenital defect coexists?

ASD may present asymptomatically, possibly with a slight murmur.

Does atrial septal defect (ASD) usually require intervention?

It often closes on its own most times.

Treatment: ASD

patients with cardiac defects are at higher risk for infection

often closes on its own

surgical repair depends on size

catheter-based repair or open-heart surgery to repair ASD

Cardiac Catheterization

Cannulation of a vein, usually in groin or neck area to pass catheter into heart or major vessels of heart

advanced with the use of x-ray fluroscopy

keep extremetits striaght for 4-6 hours with no movement; position flat on back

foley catheter may be used

check pulses above and below site (normal for pulse BELOW site to be weaker post op due to disruption of blood flow)

Auscultate for abnormal HR or rhythm and compare to pre op

monitor for bleeding with pressure dressing for 24 hours then dry occlusive dressing (bandaid, gauze, tape)

monitor for temp or color changes (check cap refill - if pale/cold blood flow not adequate)

no tub baths

observe S&S of infection

fever is common but should not last longer than 24 hours or be above 100 degrees

Risks of cardiac cath

acute hemorrhage from entry site

nausea and vomiting

loss of pulse in catheterized extremity

cardiac arrhythmia

Ventricular septal defect

abnormal opening in the wall that separates the R and L ventricles

0.4% born with

degree depends of size of defect with up to 75% of small defects closing spontaneously

Most babies are asymptomatic and hole repairs on their own

Symptoms of VSD

asymptomatic with murmur

SOB

feeding difficulties (heart in overdrive burns more calories)

murmur

FTT -> not gaining weight

recurrent respiratory infections

treatment of VSD

cardiac cath or surgical repair

Patent Ductus Arteriosus

ductus arteriosis closes shortly after birth if it does not close then it is patent ductus arteriosus

An abnormal opening between the aorta and pulmonary artery

Clinical manifestations: PDA

all or nothing (asymptomatic or CHF) (difficutly breathing and arrythmias

MACHINE LIKE MURMUR

tachycardia

bounding pulses

fatigue

FTT/poor eating

**widened pulse pressure**

low diastolic

Pulse Pressure

120/80 = 40 PP, if higher can indicate PDA

Tx: PDA

Indomethacin (Indocin)/ibuprofen

surgery to ligate artery via L thorcatomy

video assisted thorascopic surgery

Preventing bacterial endocarditis

PDA/ASD/VSD -> risk factor for it

caused by irritation of smooth muscle tissue -> created favorable medium for bacterial growth

antibiotics before oral, dental, or respiratory procedures

Co-arctation of the aorta

narrowing of the aorta between upper body and lower extremities

increased BP to head

decrease BP in the lower extremities

Clinical manifestations: co-arctation

majority start asymptomatic -> grow and develop normally

- 20-30% develop CHF by 3 mo -> no symptoms so goes undiagnosed

*higher BP in arms than legs

characteristic murmur heard at R midline or lower sternal border

**weak femoral pulses, cool legs

Leg pain can be confused for growing pains, but it is actually from a lack of blood

headache

Tx: co-arctation

ballon dilation for intital relief through umbilical artery in infants

surgical resection with end-end anastomosis -> cut and reattach

Pulmonic stenosis

Narrowing of the entrance to the pulmonary artery and resistance to blood flow cause right ventricular hypertrophy and decreased pulmonary blood flow

Symptoms: pulmonic stenosis

**SOB

cyanosis

murmurs

tx: pulmonic senosis

nonsurgical: balloon angioplasty in cath lab to dilate valve

surgical: valvotomy

Aortic stenosis

narrowing of aortic valve

causes increased resistance in the left ventricle, decreased cardiac output, and left ventricular hypertrophy

Symptoms: aortic stenosis

**faint pulses

**hypotension

poor feeding

tachycardia

murmur

exercise intolerance

chest pain

dizziness with standing

Treatment: aortic stenosis

same as pulmonic stenosis

cyanotic heart defect

deoxygenated blood bypasses the lungs and enters systemic circulation

right-to-left shunting, bidirectional shunting, malposition of the great arteries

Tetralogy of Fallot

birth defect of the heart consisting of 4 abnormalities (results in insufficiently oxygenated blood pumping to the body)

- pulmonic stenosis

- right ventricular hypertrophy

- overriding aorta

- VSD

Symptoms: TET

may not show cyanosis at birth but develop episdoes later

*blue spells or tet spells

characteristic murmur

at risk for seizures, LOC, sudden death

TET spell intervention

Place the child on its side, pull the knees up to the chest, and calm the baby

TET: interventions/parent education

feed child slowly

give smaller more frequent meals

decrease anxiety by being calm

knee-chest position

miinimize crying by anticipating child needs

Prepare the family for the possibility of multiple surgeries

transposition of the great vessels

when the aorta and pulmonary artery are transposed

cyanotic defect because it results in insufficiently oxygenated blood pumped to the body

*pulmonary artery exits left ventricle

*aorta exits right ventricle

most common cyanotic identified in first week of life

no communication between pulmonary and systemic circulation

usually associated with other defects such as ASC]D/PDA/VSD to permit blood to mix

even though oxygenated blood is mixed with non it is not enough to sustain life

**extremely blue at birth

Treatment: transposition of the great vessels

*GOAL: increase blood oxygenation

IV prostaglandins: keep ductus arteriosus open (allows blood flow to body)

Surgery: arterial switch

- done in first few weeks

- switching and re-establishing coronary arteries to establish normal circulation

- creates new aorta

*neurological and developmental complication risk is high after surgery

Hypoplastic left heart syndrome

underdevelopment of the left side of heart resulting in small aorta and left ventricle

*will have PDA and ASD in order to have blood flow through heart

Descending aorta receives blood from the ductus arteriosus

Clinical manifestations: Hypoplastic left heart

before PDA closes

- mild cyanosis

after PDA closes

- progressive deterioration with cyanosis and decreased cardiac output leading to cardiovascular collapse

skin is cold and clammy

cyanosis

abnormality in breathing

poor feeding

Treatment: hypoplastic left heart

maintenance of PDA with prostaglanding E (vasodilate it until surgery)

surgery (can be fixed but in severe cases need transplant)

heart transplant

post-op complications: hypoplastic left heart

imbalance of systemic and pulmonary blood flow

bleeding

low cardiac output

persistent heart failure

post-op concerns: hypoplastic left heart

cardiac tamponade-> compression of heart

hypothermia -> warm slowly post-op

chest tube drainage (over 3mL/kg/hr or 10-15mL/kg any hour is exessive and a problem)

SVT - superventricular tachycardia

occurs in atria

HR >220 BPM

stimulate vagal response with cold to reset heart

apply ice to forehead

adenosine IV push

Congestive heart failure

heart pumps well but very insufficient due to a structrual problem

can be result of a weak heart muscle that does not pump a normal amount of blood to the body

"rubberband theory" - the more you use it, the less it will work

CHF - impaired myocardial function

edema, poor feeding, sweaty with feeding, minimal activity, FTT, SOB, cyanosis

pulmonary congestion

sudden wt gain, tachypnea, tachycardia, increased respiratory effort

systemic venous congestion

bulging neck veins (jugular venous distention)

CHF - manifestations

poor growth

heart failure

sweaty with feedings

lungs fill with fluid

chest and belly muscles to help breathe

weight gain from edema

hepatomegaly

CHF - DX

chest x-ray

exercise test

echocardiogram

cardiac cath

MRI to see heart function

Treatment - CHF

surgery or heart transplant

Furosemide -> eliminates extra fluid in lungs

- first line med for edema

-> encourage eating potassium because diuretics pull it from body

ACE inhibitors (captopril) decrease BP or beta blockers (propanolol)

-> theoretically lowering BP will decrease workload of heart and relax it

Digoxin: improve contractility of heart and help pump blood more efficiently by slowing HR

high potassium foods

avacado, banana, potatoes, spinach, beans, citrus juices, fish

Digoxin

*can be easily over- or under-medicated

be aware of baseline parameters: pulse, BP, HR

Administer 1 hour before or 2 hours after meals

-> if child vomits DO NOT repeat dose

take apical pulse for full minute

-> changes in HR especially bradycardia is first sign of digoxin toxicity

monitor for S&S of digoxin toxic effects:

-> anorexia, nausea/vomiting, diarrhea, and visual disturbances

frequent blood draws to check dosin levels

*DUAL SIGN OFF MED*

caregiver education - digoxin

give at same time everyday -> do not double if dose is missed

nofity PCP before giving OTC meds

*DO NOT breastfeed if child is taking (can be absorbed through breast)

digoxin toxicity = vomiting

too low a dose = tired, lethargic, edema

ABCD of CHF

A- ACE inhibitors

B- Beta blockers

C - concentrated calories (fortified formula)

D - Digoxin/diuretics

Shock

inability of body to maintain adequate blood flow and oxygen supply to the tissues needed for metabolism

- 3 types

hypovolemic shock

profound dehydration or loss of blood with a decrease in hemoglobin; X-ray would show a normal heart

cardiogenic shock

Damage to the heart muscle resulting in pump failure

septic or distributive shock

shifting of fluids from the intravascular space to the extracellular space; caused by blood vessel dilation, often a result of sepsis (some sort of infection)

Shock treatment

fluids

blood and blood products

antibiotics

medications to increase BP and the delivery of oxygen to tissues

shock assessment

confusion or lack of alertness

LOC

sudden rapid heartbeat

sweating

pale skin

weak pulse

rapid breathing

decreased or no urine output

cold hands and feet